Mastectomy with one-stage or two-stage reconstruction in breast cancer: analysis of early outcomes and patient's satisfaction.

Aim of this study is to compare early post-operative outcomes and patient's satisfaction after skin-sparing and/or nipple-sparing mastectomy (SSM/SNSM) followed either by breast reconstruction with one-stage prepectoral implantation or two-stage technique for breast cancer (BC) or BRCA1/2 mutation.From January 2018 to December 2021, 96 patients (mean age of 51.12 ± 10.9) underwent SSM/SNSM and were divided into two groups: in group A (65 patients, 67.7%), mastectomy was followed by one-stage reconstruction; in group B (31 patients, 32.3%) by two-stage. Operative time was significantly longer in A vs. B (307.6 ± 95.7 vs. 254.4 ± 90.91; P < 0.05). Previous breast surgery was more common in B vs. A (29.0% vs. 7.7%; P < 0.05), while bilateral surgery was performed more frequently in A vs. B (40% vs. 6.5%; P = 0.001). All SSM/SNSM for BRCA1/2 mutation were followed by immediate prepectoral implantation. No significant differences were found between groups in terms of post-operative complications. At pathology, DCIS and invasive ST forms, such as multicentric/multifocal forms, were detected more frequently in B, while NST type in A (all P < 0.05). A multivariate analysis showed improved post-operative satisfaction at BREAST-Q survey in Group A (P = 0.001). Encouraging oncologic outcomes after SSM/SNSM for BC enabled the improvement of breast reconstructive techniques. One-stage reconstruction is characterized by better aesthetic outcomes and by greater patient's satisfaction. When SSM/SNSM is technically difficult to perform, as in multicentric/multifocal forms or previous breast surgery, mastectomy followed by two-stage reconstruction should be considered to achieve a radical surgery.

Retrospective Study of Indications and Outcomes of Open Abdomen with Negative Pressure Wound Therapy Technique for Abdominal Sepsis in a Tertiary Referral Centre.

In patients with advanced sepsis from abdominal disease, the open abdomen (OA) technique as part of a damage control surgery (DCS) approach enables relook surgery to control infection, defer intestinal anastomosis, and prevent intra-abdominal hypertension. Limited evidence is available on key outcomes, such as mortality and rate of definitive fascial closure (DFC), which are needed for surgeons to select patients and adequate therapeutic strategies. Abdominal closure with negative pressure wound therapy (NPWT) has shown rates of DFC around 90%. We conducted a retrospective study to evaluate in-hospital survival and factors associated with mortality in acute, non-trauma patients treated using the OA technique and NPWT for sepsis from abdominal disease. Fifty consecutive patients treated using the OA technique and NPWT between February 2015 and July 2022 were included. Overall mortality was 32%. Among surviving patients, 97.7% of cases reached DFC, and the overall complication rate was 58.8%, with one case of entero-atmospheric fistula. At univariable analysis, age (p = 0.009), ASA IV status (<0.001), Mannheim Peritonitis Index > 30 (p = 0.001) and APACHE II score (p < 0.001) were associated with increased mortality. At multivariable analysis, higher APACHE II was a predictor of in-hospital mortality (OR 2.136, 95% CI 1.08−4.22; p = 0.029). Although very resource-intensive, DCS and the OA technique are valuable tools to manage patients with advanced abdominal sepsis, allowing reduced mortality and high DFC rates.

A single-surgeon randomized trial comparing sutures, N-butyl-2-cyanoacrylate and human fibrin glue for mesh fixation during primary inguinal hernia repair.

BACKGROUND: We sought to determine the efficacy of sutures, human fibrin glue and N-butyl-2-cyanoacrylate for mesh fixation in patients undergoing the plug and mesh procedure for groin hernia. METHODS: A total of 156 patients with 167 inguinal hernias (11 bilateral) underwent a plug and mesh procedure and were randomly assigned to received either sutures (n = 59 hernias), human fibrin glue (n = 52) or N-butyl-2-cyanoacrylate (n = 56) for mesh fixation. RESULTS: The overall morbidity rate was 38.98% in the suture group, 9.62% in the fibrin glue group and 10.71% in the N-butyl-2-cyanoacrylate group (suture v. fibrin glue, p < 0.001; suture v. N-butyl-2-cyanoacrylate, p < 0.001). There was no significant difference in morbidity between the fibrin glue and N-butyl-2-cyanoacrylate groups. Overall, short-term morbidity was significantly higher in the suture group (27.12%) than in the fibrin glue (9.62%, p = 0.01) or N-butyl-2-cyanoacrylate (8.93%, p = 0.004) groups, but there was no significant difference between the fibrin glue and N-butyl-2-cyanoacrylate groups. There was no significant difference between the groups in terms of mean postoperative stay (32.6 h in the suture group v. 30.8 h in the fibrin glue group v. 32.0 h in the N-butyl-2-cyanoacrylate group) or mean time to return to work (20.4 d in the suture group v. 20.3 d in the fibrin glue group v. 19.8 d in the N-butyl-2-cyanoacrylate group). Overall, long-term morbidity was significantly higher in the suture group (11.86%) than in the fibrin glue (0%, p = 0.001) or N-butyl-2-cyanoacrylate (1.78%, p = 0.03) groups. There was no recurrence in any of the groups. Two cases (3.39%) of chronic groin pain were reported in patients in the suture group. A sensation of extraneous body was reported in 5 (8.47%) patients who received sutures and in 1 (1.78%) patient in the N-butyl-2-cyanoacrylate group; there were no reported cases in the fibrin glue group (suture v. fibrin glue, p = 0.01; suture v. N-butyl-2-cyanoacrylate, p = 0.03; fibrin glue v. N-butyl-2-cyanoacrylate, p = 0.30). CONCLUSION: The use of human fibrin glue or N-butyl-2-cyanoacrylate is better tolerated than sutures in tension-free inguinal open repair using the plug and mesh technique in terms of overall immediate results, and there is a better trend in the long-term data.

The effectiveness of FloSeal matrix hemostatic agent in thyroid surgery: a prospective, randomized, control study.

BACKGROUND: The objective of this study was to compare the effectiveness of FloSeal matrix hemostatic agent with hemostatic surgical procedures and Tabotamp in thyroid surgery. METHODS: One hundred fifty-five consecutive total thyroidectomy patients were recruited at our institution between January 2005 and December 2007. Exclusion criteria were applied. Patients were randomized to one of three hemostatic approaches: 49 received surgical procedures only, and 52 received oxidized regenerated cellulose patch (Tabotamp Fibrillar 2.5 x 5 cm) and 54 FloSeal (5,000 U/5 mL). The same surgeon performed all operations. RESULTS: Mean operating time was reduced in the FloSeal group (105 min) vs. surgical (133 min, p = 0.02) and vs. Tabotamp (122 min, p = 0.0003). Also, wound drain removal occurred earlier with FloSeal (p = 0.006 vs. surgical; p = 0.008 vs. Tabotamp) resulting in shorter postoperative hospital stay in the FloSeal group (p = 0.02 vs. surgical; p = 0.002 vs. Tabotamp). CONCLUSIONS: FloSeal matrix is an effective additional agent to conventional haemostatic procedures in thyroid surgery.

Botox for chronic anal fissure: is it useful? A clinical experience with mid-term follow-up.

BACKGROUND: Sphincterotomy has been the most commonly used treatment for chronic anal fissures. Although effective it is associated with incontinence (0-20%). Intrasphincteric Botulinum Toxin A injection seems to be a reliable option. The aim of this clinical report is to verify the effectiveness of this treatment in relieving symptoms and healing fissures without relapse. METHODS: The study design was an open label non-comparative prospective trial to evaluate the efficacy ofbotulinum toxin injection in anal sphincters. In the period 2003-2005 sixty patients were enrolled in our Unit of Coloproctology. After inoculation hygiene measures (sitz baths, Vaseline oil and water intake) were recommended. After the first 4 weeks without improvement we administered a second injection (30 U.I). After failure of the second administration the patient was addressed to surgery. Mean follow-up was 24 months; patients were re-evaluated at the 6th, 12th and 24th month. RESULTS: In 29 pts the fissure was healed (48.33%) after the first injection; 31 patients (51.6%) were re-treated; 20 pts presented a complete healing of the fissure in a period ranging between 4-5 weeks from the second injection and 11 patients were introduced to surgery. In 3 cases we observed haemorrhoidal thrombosis. Gas incontinence was reported in two patients and solved spontaneously. CONCLUSIONS: Our clinical experience suggests that botulinum toxin therapy can be considered effective and safe. It can be proposed to the patient as first line therapy before surgery.

Emergency surgery for acute respiratory failure secondary to spontaneous thyroid hemorrhage.

A 42-year-old woman was evaluated for an emergency at our surgical department for acute dyspnea associated with a spontaneous and rapidly enlarging mass of the neck. Clinical examination revealed a large, firm, nonfluctuant thyroid swelling on the right side of the neck. An urgent computerized tomography scan showed a hematoma within the right lobe of the thyroid and tracheal deviation with marked luminal narrowing. Because of the rapid progression of respiratory distress, endotracheal intubation by flexible laryngoscopy revealing normal vocal cords function and emergency total thyroidectomy were performed. During the operation, the thyroid gland showed a huge, edematous, nonfluctuant, rubbery, firm swelling with easy bleeding on touch, but the capsule appeared to be intact without rupture. Microscopic examination revealed a colloid multinodular goiter with massive parenchymal hemorrhage. Recovery was uneventful, and the patient was discharged 2 days after the operation.

Management of descending duodenal injuries secondary to laparoscopic cholecystectomy.

AIM: To report our experience of managing patients affected by descending duodenal injuries secondary to laparoscopic cholecystectomy and to review the literature. METHODS: Analysis of 5 cases of descending duodenal injury as a consequence of laparoscopic cholecystectomy managed between June 1992 and September 2006. RESULTS: The median age was 59 (range 49-67) years. In all cases an emergency laparotomy showed an injury to the descending duodenum. Two patients underwent direct suture of the duodenum and external biliary drainage through a T-tube, 1 case underwent a duodenojejunostomy and in another a duodenopancreatectomy. The latter patient underwent drainage of the duodenum with a Petzer tube, followed 5 days later by gastric resection, closure of the duodenal stump and repair of the duodenal wound by suture. The median postoperative stay was 45 days and 1 patient died. CONCLUSION: Descending duodenal injuries are extremely rare complications of laparoscopic cholecystectomy with potentially fatal consequences if not promptly recognized and treated. The site of the descending duodenal injury is important for determining the surgical approach.